Krishna Kumar Mohanan Nair

Persistent pulmonary artery hypertension in patients undergoing balloon mitral valvotomy.

Pulmonary artery pressure (PAP) is known to regress after successful balloon mitral valvotomy (BMV). Data of persistent pulmonary artery hypertension (PPAH) following BMV is scarce. We analyzed the clinical, echocardiographic, and hemodynamic data of 701 consecutive patients who have undergone successful BMV in our institute from 1997 to 2003. Data of 287 patients who had PPAH (defined by pulmonary artery systolic pressure [PASP] of ≥ 40 mmHg at one year following BMV) were compared to the data of 414 patients who did not have PPAH. Patients who had PPAH were older (39.9 ± 9.9 years vs. 29.4 ± 10.1; P < 0.001). They had higher prevalence of atrial fibrillation (AF; 21.9 vs. 12.1%, P < 0.05), moderate or severe pulmonary artery hypertension (PAH) defined as PASP more than 50 mmHg (43.5 vs. 33.8%, P = 0.00), anatomically advanced mitral valve disease as assessed by Wilkins echocardiographic score > 8 (33.7 vs. 23.2%, P < 0.001), and coexistent aortic valve disease (45.6 vs. 37.9%, P < 0.001) at the baseline. Those patients with PPAH had comparatively lower immediate postprocedural mitral valve area (MVA). On follow-up of more than five years, the occurrence of restenosis (39.3 vs. 10.1%, P = 0.000), new onset heart failure (14% vs. 4%, P < 0.05) and need for reinterventions (9.5% vs. 2.8%, P < 0.05) were higher in the PPAH group. Patients with PPAH were older, sicker, and had advanced rheumatic mitral valve disease. They had higher incidence of restenosis, new onset heart failure, and need for reinterventions on long term follow-up. PPAH represents an advanced stage of rheumatic valve disease and indicates chronicity of the disease, which may be the reason for the poorer prognosis of these patients. Patients with PPAH requires intense and more frequent follow-up.

Immediate and Long-term Results Following Balloon Mitral Valvotomy in Patients With Atrial Fibrillation

The purpose of this study was to examine the influence of atrial fibrillation (AF) on the immediate and long‐term outcome of patients undergoing balloon mitral valvotomy (BMV).

Asymptomatic right ventricular dysfunction in surgically repaired adult tetralogy of fallot patients

Background: Right ventricular (RV) dysfunction after surgical repair of Tetralogy of Fallot (TOF) is often asymptomatic and may be detected by tissue Doppler imaging (TDI). The severity of RV dysfunction is more after intracardiac repair with transannular patch (TAP). Methods: One hundred seventy-three adult patients who have undergone surgical repair for TOF were prospectively analyzed for RV function using 2D echocardiography and TDI. RV function was compared between patients who have undergone intracardiac repair with and without TAP. Results: In both the patient sub-groups, TDI derived myocardial performance index (MPI) and myocardial velocities were abnormal even when 2D echocardiography derived RV functional area change was normal. TDI derived MPI was significantly higher (0.5 ± 0.1 vs. 0.4 ± 0 P < 0.001) and Systolic tricuspid annular velocity (Sa) (9.2 ± 1.3 vs. 10.8 ± 1.6 P < 0.001) was significantly lower in the TAP group. Older age at surgery and severity of pulmonary regurgitation on follow-up were among the significant predictors of TDI derived MPI. Conclusions: Asymptomatic RV dysfunction in surgically repaired adult TOF atients can be detected by TDI. Extent of RV dysfunction was significantly greater with patients requiring TAP, in those operated at older age, and in patients with severe pulmonary regurgitation.

Comparative study on safety, efficacy, and midterm results of balloon mitral valvotomy performed with triple lumen and double lumen mitral valvotomy catheters.

The triple lumen Inoue balloon is routinely used for Balloon Mitral Valvotomy (BMV) in India. Its major limitation is the high cost. The double lumen Accura balloon is less expensive, making it an attractive alternative in the developing countries. The study was meant to assess the safety, efficacy and midterm results of Accura balloon with respect to the Inoue balloon.

Paradoxical Increase in Stimulus to Atrium Interval During Para-Hisian Pacing

A 40-year-old gentleman has undergone electrophysiological study for paroxysmal palpitation. Surface electrocardiogram during sinus rhythm showed no preexcitation. The AH and HV intervals during sinus rhythm were 104 and 40 ms, respectively. There was no dual AV node physiology demonstrated. Para-Hisian pacing was performed to exclude a septal bypass tract which showed an interesting response (Fig. 1). Para-Hisian pacing demonstrated relatively broader (104 ms) and narrow (60 ms) QRS morphologies with stimulus to atrium (S–A) intervals of 156 and 175 ms, respectively. The atrial activation sequence with the 2 QRS morphologies is not similar (Fig. 2). The ventricular activation has also changed from the left to the right panels, with the proximal left ventricle (as suggested by the V electrogram [EGM] in the coronary sinus [CS] electrodes 5, 6, 3, 4, 1, and 2) and para-Hisian right ventricle are relatively early when the QRS

An interesting case of narrow QRS tachycardia with incomplete right bundle branch block morphology: What is the mechanism?

A 20-year-old woman with no structural heart disease is referred for radiofrequency catheter ablation of narrow QRS tachycardia that is terminated with intravenous adenosine. Twelve-lead ECG was normal during sinus rhythm. At the basal state, sinus cycle length (SCL), atrio-Hisian (AH), and Hisio-ventricular (HV) intervals are 614 ms, 82 ms, and 42 ms, respectively. Incremental ventricular pacing from the right ventricle (RV) showed concentric atrial activation with decremental conduction suggesting retrograde nodal

Atrial overdrive pacing during wide QRS tachycardia with RBBB morphology. What is the mechanism?: MOHANAN NAIR et al .

Department of Cardiology, SreeChitra Tirunal Institute forMedical Sciences and Technology, Thiruvananthapuram, Kerala, India Correspondence NarayananNamboodiri,DepartmentofCardiology, SreeChitraTirunal Institute forMedical Sciences and Technology, Thiruvananthapuram,Kerala695011, India. Email: kknnamboodiri@gmail.com Disclosures: Theauthorshavenocompeting interests, funding, or financial relationships todisclose.

Narrow QRS tachycardia with AV response from 2:1 to 1:1. What is the mechanism?

Received 31 January 2016; revision accepted for publication 24 March 2016. A 55-year-old female underwent an electrophysiology study for paroxysmal palpitation. Panel A represents the surface electrocardiogram showing narrow QRS tachycardia with 2:1 AV relation transforming to 1:1 AV conduction following a premature ventricular ectopic (PVE). Panel B represents the intracardiac electrogram of the same phenomenon. The tachycardia cycle length, ventriculo-atrial interval and retrograde atrial activation sequence during 2:1 AV conduction and 1:1 AV conduction remained the same. Panel C represents ventricular overdrive pacing during the narrow QRS tachycardia with 1:1 AV conduction showing pseudo V-A-A-V response between fifth and sixth ventricular beats on cessation of pacing, suggestive of fast slow AV nodal Narrow QRS tachycardia with AV response from 2:1 to 1:1. What is the mechanism?

The role of high-intensity focused ultrasound in ablation of atrial fibrillation and other cardiac arrhythmias

Atrial fibrillation is the most prevalent arrhythmia of the heart, originating usually from ectopic atrial activity of the pulmonary veins. Therefore, one of the treatment options is pulmonary vein isolation. Among the novel approaches to pulmonary vein isolation, high- intensity focused ultrasound (HIFU) has been developed. The ultrasound energy can be focused on a specific area and would result in the formation of a lesion similar to that formed with radiofrequency (RF) ablation. Although preclinical studies were promising, clinical studies in patients resulted in lower efficacy and high complication rates in comparison to the standard ablation method, due to collateral damage. Using HIFU for epicardial approach during cardiac surgery and for extracorporeal ablation does seem to have a future role. In this review, we pres- ent the mechanism of HIFU lesion formation and the principal studies.

Stenting versus surgery for atrial-esophageal fistula.

We read with great interest the article on atrialesophageal fistula (AEF) outcome with stenting versus surgical repair.1 We commend Mohanty et al. for this report that helps us better understand the management of this rare but dreadful complication. Mohanty’s work, in conjunction with other sporadic cases of stenting for AEF, supports the importance of early surgical repair when possible. Given the possibility of selection bias, we are interested if Monanty can comment whether patients undergoing stenting in their series would have otherwise been candidates for surgical repair? Furthermore, did the authors note any immediate peristenting deterioration related to esophageal air insufflations for stent placement or stent erosion? Knowledge of these 2 points is important to better understand the role of stenting for this condition as it is possible that stenting may be a temporary solution in order to facilitate transfer to a surgical center with experience managing AEF. We would like to highlight the surgical repair performed in all patients in Mohanty’s series that supports our prior work demonstrating that primary esophageal repair and interposition of a pericardial or intercostal muscle flap was